Provider Demographics
NPI:1023311008
Name:NEIL D. FAGEN,M.D.,INC.
Entity type:Organization
Organization Name:NEIL D. FAGEN,M.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-996-4796
Mailing Address - Street 1:18411 CLARK ST
Mailing Address - Street 2:204
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3535
Mailing Address - Country:US
Mailing Address - Phone:818-996-4796
Mailing Address - Fax:818-996-4793
Practice Address - Street 1:18411 CLARK ST
Practice Address - Street 2:204
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3535
Practice Address - Country:US
Practice Address - Phone:818-996-4796
Practice Address - Fax:818-996-4793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G293040Medicaid
CA00G293040Medicaid